NCP - Risk For Infection

 

NURSING CARE PLAN PROBLEM

EXPLANATION OF

OBJECTIVE

THE PROBLEM

Status

post

VP The

shunting Incision at right sub coastal area S – “d “dal alaw awa a yu yung ng su suga gatt ni niya ya sa ul ulo, o, linagyan daw ng tubo pa para ra maal maalis is yung yung tubig sa loob – medy medyo o nama namama maga ga

patient

NURSING

RATIONALE

EVALUATION

INTERVENTION

is

sch ched edul ule ed f or or VP shunting due to increased intracranial pressure and diagnosis of   destructive hydrocephalus measuring 2.1 x 1.7 x 1.8 cm whic which h are secondary to

LTO : after 3 days of  Dx : Nursing Intervention the client will be able to pre preven ventt the risk for infection STO : After 8 hours of   nursing intervention, the the clie client nt wi with th the the help of the significant

Dx : 1.monit 1.mon itor or signs

Assess patient’s

2.

vita vitall

the

nga ata eh” as pituitary adenoma othe others rs wi will ll be able able verbalized by to: patient’s patie nt’s significa significant nt The patient is 1. per perfor form m others sch ched edul ule ed f or or VP independently shunting wherein the pr pro ope perr wound und O – inc incisi ision on site at excess CSF is care right subcoastal area removed to decrease 2. tta ake in of head. intracranial pressure. fo food ods/ s/di diet et that that - patient is lying on There are two wo woul uld d pr prom omot ote e bl blan anke kett from from th thei eirr incision sites done at faster wound

knowledge about knowledge condition. In addition, the significant others knowledge know ledge since since the pat patien ientt may be unable unable to do such such bec becaus ause e of  neurologic disturbances

-house pre prese sence nce of thick thick terminal hair around incision sites - infl inflam amma mati tion on at right side of head - rubo ruborr an and d ca call llor or around the wounded part - WBC count is below

3. ass assess ess adequacy of   blood supply and inne innerv rvat atio ions ns of  the affected tissue

th the e htpa pati tien ent’ t’s sbcoa he head ad (r (rig ight su subc oast stal al area). Excess cerebrospinal fluid is drained for palliative reasons. A break break in the firs firstt line of defense by the body, the skin, would

healing 3. identi identify fy interventions that could coul d preve prevent nt or re redu duce ce the the ri risk sk for infection 4. ach achiev ieve e timely timely wo woun und d he heal alin ing, g, free from signs of  infection

Criteria

1. this would After 3 determine if   days of   ther there e has has be been en Nursing systemic Intervention infection the cli client ent was occurrin occu rring g inside inside able to prevent the body the risk for infection 2. determine patien patient’s t’s abilit ability y The client with to perform independent interventions together with her significant others

the help of the significant others was able to: perform independen tl tly y pr prop oper er wound care ta take ke in foods/diet •

•

3.

determining determini ng the blood bloo d supply supply for proper oxyg oxygen enat atio ion n of  the tissues which would aide in the progress of   he heal alin ing g of th the e affected tissue

tha thatt would would promote faster wound healing identify interventio ns that could preven preventt or •

Result

 

no norm rmal al at 4.2 4.2 G/L G/L (ref (ref.. va valu lue e – 5. 5.0010.0 G/L) - pa pati tien entt is ha havi ving ng

promote the entrance of microo microorga rganis nisms ms which can cause inf infect ection ion at wound wound

and IVF side drip of  sit site e or eve even n sep sepsi sis s PLNSS 500ml + throug through h the bod body’s y’s tramadol x 24 hours blo blood od cir circul culati ation on if  not treated properly A – Risk for Infection relate related d to break break in the the sk skin in inte integr grit ity y (rig (right ht su subc bcoa oast stal al area of head) secondary seco ndary to status status

verbalize feelings of   understanding, recovery and

5.

comfort

4.

assess changes

4.

of  

wo woun und d si site te fo forr de dept pth, h, w iidt dth h, color, smell, location, temperature, texture, and discharges

post VP shunt

obtain specific tissue tiss ue or fl flui uid d spec specim imen en from from the wound

5.

Provides comparative baseline

for

clean the wound every shift or as requ requir ired ed usin using g po povi vido done ne iodine

1.

•

future assessme asse ssment nt and pro promot mote e tim timely ely nursing interven inte rvention tion and rev revisi ision on of care care plan. It also det determ ermine ines s the risk or degree of  infec infectio tion n of the

timely wound healing, f re ree f ro rom signs of   infection verbaliz e feel feelin ings gs of  understandi

wound

ng, recovery and comfort

5. determine is there is infection and provide information abou aboutt nurs nursin ing g interven inte rvention tions s to be planne planned d and performed Tx :

Tx :

red reduce uce the risk for infection achieve

1. prom promotes otes faster wound healing and prevent infection at the wound site 2. prev prevent ent accumulat accu mulation ion

of 

•

 

2. change change dressings needed

as or

required

exuda date tes s and and pro prolif lifera eratio tion n of  microorganisms on the dressing, preventing further infection

3. mainta maintain in adequate hydration

by

proper regulation of IVF and giving fluids as indicated 4. prov provid ide e go goo od nutrition by giving diet rich in protein and calories, and

3. prev prevent ent dehydrati dehy dration on and provide electrol elec trolytes ytes and minerals mine rals neede needed d by th the e bo body dy to recover promotes faster wound healing and provide the patient adequate source of energy for recovery 4.

5.

vitamins minerals

and/or

5. pro promot mote e ear early ly mobility by providing position change cha nges, s, act active ive or passive exer exerci cise ses s an and d assistive

cirpromote c cu ul at ati o on n better at bo body dy pa part rts s and and prevent excessiv exce ssive e tiss tissue ue pres pressu sure re th thus us promotin prom oting g faster faster wo woun und d heal healin ing g and recovery

 

exercises 6. prev prevent ent inf ec ecti tio on dete determ rmin ine e 6. administe administerr and monitor medication regimen like anti antibi bio oti tic c an and d noting noting patien patient’s t’s response Ed Ed : 1. enco encour urag age e pa pati tien entt to have have adequate periods of rest and sleep 2.

teach the patient and and si sign gnif ific ican antt others how to do pr pro oper per wo oun und d caring

and th the e

eff effect ective ivenes ness s of  therapy and presence pres ence of side effects

: 1. s sa ave and rest restor ore e ener energy gy for recovery

2. enab enable le cl clie ient nt and and si sign gnif ific ican antt others if the cli en ent can ann not perform it, to do pr o ope perr wound care independently

tpr ha t ote w uer ld prom omot e fast faoster wo woun und d heal healin ing g and recovery let the patient patient and and si sign gnif ific ican antt others appreciate the import importanc ance e of wound caring caring

3. 3.

teach patient and significant others the importance of  pr pro oper per wo oun und d

 

care

4. te teac ach h pa pati tien entt the the i mpo mporr tta anc nce e of   good good nu nutr trit itio ion n during during and after after recovery

that would prom promot ote e fast faster er wo woun und d heal healin ing g and recovery 4. let the pat patien ientt appr apprec ecia iate te the the role role of prop proper er diet on his recovery and allow allow pat patien ientt to continue his proper diet during his recovery let the patient patient appr apprec ecia iate te the the im impo port rtan ance ce of  earl early y mo mobi bili lity ty that would prom promot ote e be bett tter er cir c cu ul at ati o on n at body bod y parts parts thus thus

5.

5. te teac ach h pa pati tien entt the the i mpo mporr tta anc nce e of   ea earl rly y mo mobi bili lity ty and exercises

promotin prom g he faster faste wo woul uld doting heal alin ing gr and recovery

6.

encourage ver verbal baliza izatio tion n of  feelings and expectations reg egar ardi din ng he err

6. pr pro ovi de de th the e nurs nurse e a pl plan an or rev revisi ision on of care care appr approp opri riat ate e for for the patient and/or allow

 

condition

nurse to determine needs determine of patient patient either either spiritual, emot emotio iona nall and and physiological